Mental health in Nigeria: A Neglected issue in Public Health.

In Nigeria, the disparity between available healthcare services and need for mental health services is palpable. Although, the country has made significant advances on challenging public health problems, health-related policy development and legislation in trying to achieve health for all policy, there have been challenges with regards to mental health services including that of policy development and legislation, financing, research, training and integration of mental health care into primary health care. We consulted relevant publications, official document, policy statement, blueprints, working plans of the relevant organizations responsible for mental care and services locally and globally. We identify and highlight challenges faced in mental health services implementation and provide recommendations as way forward and call for urgent action to government, non-governmental organizations (NGOs), policy makers and legislatives which are urgently needed to reform and implement them for a better, accessible, and affordable mental health services for the mental well-being of the populace.

Introduction

Mental health is an integral part of health and well-being, and yet it's been neglected in this part of the world. Furthermore, the World Health Organizarion (WHO) estimates that worldwide, 450 million people have a mental disorder and 25% of the population will suffer from mental illness at some times in their lives [1]. According to the WHO, mental health is; “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” [2]. In 2019, a survey on mental health in Nigeria, by Africa Polling Institute (API) and EpiAFRIC shows how awareness of mental health is low in Nigeria, with most respondents been aware that they have mental health disorder, recognized it and commonly caused by drug abuse, possession by evil spirits and sickness of the brain and majority of the patients are taken to a prayer house for spiritual interventions [3]. Nigeria is also currently under multiple public health challenges as many other countries around the globe, such as COVID-19 pandemic, health and social workers' burnout, suicidal episodes, communal violence and insecurity that can lead to mental health issues. Thus, this commentary provides insights and recommendations on mental health services for policy makers and other stakeholders which may add to the heroic efforts on mental health care and services in Nigeria.

Nigeria's health system and mental health services

Nigeria being the most populous country in Africa has achieved remarkable progress in the health sector with giant successes to meet the challenges of Ebola virus, COVID-19 and other epidemics through strengthened leadership, policies and legislation. The country's health care system is composed of three tiers; the primary health system mostly accessible in rural areas and every ward of local government which is being managed by the local governments authorities in collaboration with state governments and international donor organizations, and cases being referred to secondary and tertiary care when needed. The secondary health care which mainly comprises the comprehensive health centers and general hospitals being managed by states governments. While the tertiary health systems which consist of the federal medical centers, specialist hospitals and teaching hospitals being managed by the federal government of Nigeria and in few cases by the state governments.

Workforce, policy and legislation

The burden for mental health disorder is very high with limited access to available and affordable mental health services in the country [1]. In Nigeria, many cases of mental health problems are being managed by psychiatrist (mainly consultants, residents and general physicians), nurses, social workers, occupational therapist, auxiliary staff on mental health, religious clerics and traditional care attendants leading to the diagnosis, treatment and rehabilitation of patients with mental health disorders. Patients receive care (inpatient/outpatient) and treatment in hospitals and majorly in their communities. The psychiatrists and other mental health specialists are mainly available at tertiary healthcare centers to review and treat complex cases. Nigeria with over 190 million population [5], have fewer than 300 psychiatrist accounting for a ratio of about 700,000 of the population per psychiatrist (1; 700,000), most of whom are urban based, and in view of poor knowledge of mental disorders at the primary health-care level, caring for people with mental illness is typically left to family members [6]. Furthermore, nine out of every ten doctors in Nigeria are seeking to leave the country and only eight neuropsychiatric hospitals are available in the entire country responsible for professional training of psychiatric doctors as well as managing patients with psychiatric disorders [7]. The psychiatrists are being trained in tertiary health institutions as residents while other health care professionals are being trained in post-basic programmes for nurses and other institutions for pharmacist, social workers, occupational therapists and auxiliary staff. In Nigeria, there is a lack of coherent and comprehensive mental health laws and policy. Nigeria's mental health legislation which was called Lunacy Ordinance was first enacted in 1916 which was also renamed and amended as Lunacy Act of 1958 which gives power to magistrates and medical practitioners to detain an individual suffering from mental illness [6]. Since then, the legislation has not been fully amended as there was passage of bills by the National Assembly in 2003 and also in 2013 but is yet to be signed into law by the government. In 2019, the Nigerian Senate also held a public hearing for the Mental and Substance Abuse Bill aims at strengthening budgetary allocations and recovery services for mental health and substance-use disorder but also wasn't passed or signed. More so, the first Nigeria's mental health policy was first formulated in 1991, but no provision for disaster/emergency preparedness plan in case of challenging public health crises like COVID-19 pandemic [4]. These policies are not fully implemented and non-governmental organizations like Mentally Aware Nigeria Initiatives (MANI), Mental Health Foundation, Neem Foundation, Love, Peace and Mental Health Foundation (LPM), She Writes Woman, have all stepped-up in a heroic manners to provide support programmes and activities involved in individual assistance such as housing, support services, counselling, awareness, to improve the quality of life of people living with mental health problems in Nigeria.

Mental health financing

Although disparities remain in accessing healthcare services with limited access to available and affordable health services with many of the population paying health expenses out-of-pocket. The Nigeria's health sector and health services are being mainly financed through either the public sector, financed through taxes; the private sector, financed through voluntary insurance schemes; and the social security sector, financed through obligatory insurance schemes for only people in the formal sector. The mental health budget mainly financed through the central government health budget is about 3.3–4%, with over 90 % going to the few neuropsychiatric hospitals available in Nigeria [3,4].

Recommendations

Integrating mental health into primary health care

Primary healthcare is usually the first point of care and contact within the healthcare system. In many countries around the world, treatment, integration and provision of mental health care through the primary health system have been practiced for a very long time. Furthermore, countries like Argentina, Australia, Belize, Chile, India, Iran, Saudi Arabia, South Africa, Uganda, Ireland, United Kingdom and many others have recognized mental health as an integral part of primary care to treat mental health issues like any other condition included in the primary care service packages [8,9]. Integrating and providing mental health care and treatment through primary health care will enhances access, affordability, cost effectiveness and promote respect for human right which will ultimately provide good health outcomes [8]. This call for establishment and integration of mental health care as community-based rehabilitation centers in rural areas with strong primary care network providing complementary care in close coordination with secondary and tertiary care centers. This can also serve as a site for rural posting for psychiatric residents in training and practicing primary care physicians and nurses. This will have a positive impact in addressing mental health challenges in the country.

Legislation and policy

Mental health integration into PHC is most successful when it is supported and incorporated into health policy and legislative framework with adequate resources, strengthened leadership and effective governance [8]. The WHO has also sets a global target for 50 % of countries to have developed or update their mental health laws in line with regional and international human rights instrument by 2020 through the WHO mental health action plan 2013–2020 [9]. For Nigeria to have an efficient and effective integration of mental health services in public health, there is need for reform of the outdated existing laws and formulation of new policies that will see the establishment of commission for mental health with a mission to protect and support persons with mental health needs in Nigeria.

Human resource training and competencies

There is need to establish more training institutions for different health care professional to increase the workforce on psychiatry and mental health support professionals. There should also be routine public enlightenment, outreach, training programmes and supervisory visits by specialist to support other healthcare facilities in identifying mental health disorders and referred them to appropriate care centers accordingly. Professional organizations such as Association of Psychiatrist and Nigeria Medical Association (NMA) can provide free-outreach and tailored training programs to general physician and nurses on mental health care skills.

Research and development

Research and information about the level of mental health services in Nigeria are very hard to come by or non-existent which has contributed towards neglect of mental health issues [4,8]. There is an urgent need for more investment from government and NGOs on research, and development as well as an information center on current trends, areas of need and unmet need on mental health services to help make inform decisions on policy directions, identifying appropriate interventions and to monitor progress. These will help to trigger national surveys on the subject matter so as to develop policy direction, blueprints and legislation on facts and evidence-based research and outcomes.

Awareness and public education

Although various NGOs, professional associations, friends of hospitals (philanthropists), international agencies have created a lot of awareness and public education on mental health in Nigeria most especially on media and urban places. Nonetheless, there is need for the National Orientation Agency (NOA) to collaborate with the Federal Ministry of Health (FMOH) to create more strategic communication and coordinate the public education and awareness campaigns on mental health and mental disorders especially within educational institutions, communities and rural areas. These awareness campaigns and public education should be targeted on violence victims, healthcare workers, military and law enforcement officers, prisoners and minority groups like the homeless and social deviants, drug addicts and drug abusers, children/adolescent and students [10]. There is also need to mainstream courses or school-based activities in secondary and tertiary educations to prevent mental disorders and promote mental health.

Digital therapy

In Nigeria, most NGOs programmes on mental health runs through the digital platform like Twitter, Facebook, WhatsApp, Emails and Hotlines calls. Leveraging the impact of digital health will go a long way towards access to mental health services in Nigeria and augmenting the efforts of such organization. Mental health professionals, private organizations and digital health companies as part of their corporate social responsibility (CSR) can provide accessible and available digital platforms to give counselling, as well as guidance on mental health issues and provide referral system to mental health care.

Conclusion

There is an urgent need for concerted effort between the government, policy makers and international organizations to implement the recommendations provided herein for a better, accessible, and affordable mental health services for the mental well-being of the populace in promoting mental health care and services.

Authors’ contributions

Yusuf Hassan Wada conceived the idea, Yusuf Hassan Wada, Linu Rajwani, Emmanuel Anyam, Evelyn Karikari, Mitchelle Njikizana wrote the draft of the manuscript, collect data and literature. Yusuf Hassan Wada, Lilian Srour and Garba M. Khalid critically reviewed the manuscript. All the authors read and approved the final manuscript.

Funding

We did not receive any financial support in any form regarding the study.

Ethics approval and consent to participate

Not Applicable.

Consent for publication

Not Applicable.

Availability of data and materials

Not Applicable.